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General Price List
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Vital Information
Please be as complete and accurate as possible. All this information is needed to complete legal documents. At this time a minimal number of required fields are marked with an " * ". If you have any questions please call us at 515-331-6538.
Information About The Person Completing This Form
* Informant's Name
* Relationship to Member
Mailing Address
City or Town
Zip Code
* Phone Number
* Email Address
Information About the Member
* Full Legal Name of the Member
Residence Address
City or Town
Zip Code
Inside City Limits?
* Sex
* Birth Date
Social Security Number
Place of Birth
Citizen of What Country?
Marital Status
Surviving Spouse's
(full name prior to any marriage)
Father's Name
Mother's Name
(Before first marriage)
Usual Occupation
(Do not use Retired)
(Do not use company name)
Years in Occupation
Armed Forces Information
Ever in US Armed Forces?
If yes complete the following:
Branch of Service
Serial Number
Date Enlisted
Place of Enlistment
Date Discharged
Place of Discharge
Rank at Discharge
Name of War
Education and Race Information
Member's Education
Select the option that best describes the highest degree or level of school completed at the time of death.
Member of Hispanic Origin
Select the option that best describes whether the member is Spanish/Hispanic/Latino.
If other Hispanic origin, please specify
Member's Race
Select the option that best describes what race the member considered himself or herself to be.
Additional Specification:
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